Clinical presentations and pathology of stroke

1. Clinical presentations and pathology of stroke น.พ. พรชัย สถิรปัญญา สาขาประสาทวิทยา ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ ม.สงขลานครินทร์ ประชุมวิชาการชมรมประสาทวิทยาศาสตร์ภาคใต้ ครั้งที่ 7 โรงแรมวัฒนาพาร์ค จ. ตรัง 07/12/2550

2. Stroke is an emergency !

3. หัวสมอง โรคหลอดเลือด หัวใจ หัวแม่เท้า

4. Cerebrovascular disease (CVD) or Stroke • Definition:Arupt focal or global neurological dysfunction lasting more than 24 hrs, leading to death, caused by no other causesthan cerebrovascular in origin.

5. How to diagnose stroke • Clinical presentations • Neuro-radiological studies -imaging : anatomical and physiological -ultrasonology • Genetic study eg, CADASIL • Pathological studies

6. Clinical presentations

7. “ stroke” • Stroke by clinical diagnosis requires : -Risk factors of cardiovascular diseases -Sudden onset of neurological deficit -The deficit is explainable by neurovascular syndrome *Exclusion of other causes !?

11. Non stroke • Tumor • Focal infection • Demyelination Arupt neurological deficit 95 % 5%

12. Anatomical Dx • Supratentorium • (carotid system) • Infratentorium • (vertebre-basilar • system)

13. Stroke classification (anatomy) • Carotid system stroke : - hemipaparesis and facial palsy UMN - aphasia or other cortical dysfunctions • Vertebrobasilar system stroke - hemiparesis and contralateral facial palsy LMN (or other Cranial n. palsy) - cerebellar and brain stem disorders

14. ลานฝั่งนที อ.เมือง สงขลา สงขลาฝั่งนที กลิ่นสารภียังติดเตือน...........

15. Stroke classification Pathological: arterial • Ischemic stroke (C.infarction) 85% - Thrombotic stroke Large vs. small vss. disease - Embolic stroke • Hemorrhagic stroke (C. hemorrhage) 15% - Intracerebral hemorrhage - Subarachnoid hemorrhage - Intraventricular hemorrhage

17. Thrombotic stroke

18. cerebral embolism

19. Thrombotic stroke Embolic stroke

20. Hemorrhagic stroke

21. Brain computed tomography showing extensive intracerebral hemorrhage inthe right hemisphere, involvingbasal ganglia and thalamus,with intraventricular hemorrhage. CT head scan showing right intracerebral hemorrhage secondary to ruptured right middle cerebral aneurysm

22. Hemorrhagic stroke

23. Subarachnoid hemorrhage

24. 1 2 Image 1. This is a brain CAT scan image. The yellow arrows point to two aneurysms. Image 2. This is also a brain CAT scan image. The yellow arrow points to a ruptured giant brain aneurysm with some clot (thrombus) within the main aneurysmal sac. The green arrow heads point to blood in the subarachnoid space. This image therefore shows aneurysmal subarachnoid hemorrhage (SAH).

25. 3 4 Image 3. This is a brain magnetic resonance angiogram (MRA). The image is a "scout" image of the Circle of Willis at the base of the brain. The yellow arrows point to six different brain aneurysms. Image 4. show multiple brain aneurysms (yellow arrows). One of the aneurysms has an irregular "daughter sac" (DS) coming off its dome.

26. Subarachnoid hemorrhage

27. cerebral aneurysm

28. Stroke classification • Pathological: venous -Cerebral dural sinus thrombosis -Cerebral cortical v. thrombosis -Internal cerebral v. thrombosis

29. “Empty delta sign” in Sup. saggittal sinus thrombosis

30. Internal cerebral v. thrombosis

31. Risk factors

32. Risk factors • Modifiable risk factors • Potentially modifiable risk factors • Non-modifiable risk factors

33. Well-documented risk factors • Modifiable, value established • -Hypertension • most significant modifiable risk factor • Relative risk x 4

34. . Overall relative risk of total stroke according to approximate usual diastolic blood pressure 18 studies, 1798 events in 124774 participants Lancet 1998;352: 1801-1807

35. Modifiable, value established • - Cardiac disease • Atrial fibrillation • Infective endocarditis • Mitral stenosis • Recent large myocardial infarction

36. Modifiable, value established - Cigarette smoking - Sickle cell disease - Transient ischemic attacks - carotid stenosis

37. Potentially modifiable -Diabetes mellitus -Hyper- homocysteinemia -Left ventricular hypertrophy

38. Nonmodifiable Age Gender Hereditary/familial factors Race/ethnicity Geographic location

39. Less well-documented risk factors - Elevated blood cholesterol and lipids - Cardiac disease Cardiomyopathy Patent foramen ovale Atrial septal aneurysm Aortic stenosis Mitral valve prolapse

40. Overall relative risk of haemorrhagic and non-haemorrhagic stroke, according to approximate usual cholesterol concentration Lancet 1998;352: 1801-1807

41. - Use of oral contraceptives - Consumption of alcohol - Use of illicit drugs - Physical inactivity

42. ทะเลสาบสงขลา

43. Neuro-radiological studies (anatomical scan)

44. CT scan brain

45. Magnetic resonance imaging (MRI)

46. Magnetic resonance angiography (MRA)

47. Cerebral angiogram

49. Neuro-radiological studies(physiological scan)

50. Diffusion-perfusion miss-match